Provider Demographics
NPI:1598555310
Name:JOHNSON, DERRICK
Entity type:Individual
Prefix:
First Name:DERRICK
Middle Name:
Last Name:JOHNSON
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:45 N 6TH ST APT 391
Mailing Address - Street 2:
Mailing Address - City:ALLENTOWN
Mailing Address - State:PA
Mailing Address - Zip Code:18101-1104
Mailing Address - Country:US
Mailing Address - Phone:425-999-5913
Mailing Address - Fax:
Practice Address - Street 1:5410 LYNX LN #290
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:MD
Practice Address - Zip Code:21044
Practice Address - Country:US
Practice Address - Phone:410-910-9716
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-05-07
Last Update Date:2025-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD185891223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice